Surgeries, Volume 2, Issue 2 (June 2021) – 11 articles

Introduction: Integrative medicine (IM) is a relatively new field where non-traditional therapies with peer-reviewed evidence are incorporated or integrated with more traditional approaches. Methods: A systematic review of the literature from the last 10 years was done by searching clinical trials and randomized-controlled trials on Pubmed that discuss nutrition, supplementation, and lifestyle changes associated with “Pancreatic Cancer.” Results: Only 50 articles ultimately met the inclusion criteria for this review. A total of 15 articles discussed the role of obesity and 10 discussed the influence of stress in increasing the risk of pancreatic cancer. Six discussed the potential beneficial role of Vitamins, 5 of cannabinoids, 4 an anti-inflammatory diet, 3 of nut consumption, 2 of green tea consumption, 2 of curcumin supplementation, 1 role of melatonin, and 1 of probiotics. One article each was found on the theoretical benefits of adhering to either a Mediterranean or ketogenic diet. Discussion: As more surgeons become interested in IM, it is hoped that more diseases where the curative treatment is mainly surgical can benefit from the all-encompassing principles of IM in an effort to improve quality of life and survival in patients with pancreatic cancer. Full article

There is currently little understanding of bariatric patients’ experiences and expectations of the bariatric pre-surgery evaluation (PSE) process. This is especially true for patients within the National Health Service (NHS) in the UK. Consequently, this study undertakes a qualitative study to explore the experiences and expectations of the bariatric PSE amongst patients who had undergone bariatric surgery within the NHS in the UK, using the Interpretative Phenomenological Analysis. Three inter-related superordinate themes were presented: (i) ‘PSE was challenging but essential’, (ii) ‘Coping processes to deal with the PSE’, and (iii) ‘Staff and service evaluation’. Most participants had conflicting feelings about the PSE process as it had both positive and negative impacts on their wellbeing. The process was considered essential for preparation and successful post-surgery adjustment, though the uncertainty of approval was experienced as very distressing. Consequently, participants utilised both external and internal coping strategies, such as social support, researching, or ‘toeing the line’. Participants’ experiences encouraged them to provide feedback about the staff and service, which revealed a preference for a tailored evaluation process. The emerged themes represent an initial framework for helping healthcare providers and researchers to involve patients in service delivery thereby facilitating a patient-centred approach. A starting point is to audit patients’ perspectives routinely. Further investigations are needed to better define, validate, and understand constructs and processes identified in this study. Full article

We report a patient with COVID-19 requiring hospitalization for two weeks, complicated by multiple segmental pulmonary embolisms for which dabigatran was initiated. After clearing the infection, the patient remained asymptomatic for 5 months. He was then readmitted with a spontaneous haemothorax, most likely related to the use of dabigatran, which progressed to a pleural empyema with a trapped lung. The patient underwent a video assisted thoracoscopy (VATS) with decortication. Because of focal abnormalities, biopsies for histopathology were taken from the lung parenchyma. These showed an organizing pneumonia with progression towards fibrosis and arteries with intimal fibrosis. So far, no histopathological reports exist on late pulmonary changes after a COVID-19 infection. The unusual combined presence of microvascular damage and interstitial fibrosis may reflect a pathophysiological concept in which early endothelial damage by SARS-CoV-2 can lead to a chronic state of microvascular damage, low grade inflammation, and early progression towards pulmonary fibrosis. Full article

Introduction: Common femoral artery endarterectomy (CFE) is considered a relatively simple, successful and safe procedure in the literature, but major complications can occur. This retrospective study was performed in order to define characteristics contributing to success or failure after common femoral artery endarterectomy, either performed as a single or hybrid procedure. Methods: A total of 298 patients who underwent CFE in our hospital between 1 January 2011 and 1 January 2017 were included. After exclusion, 227 patients were analyzed. Patient characteristics and outcomes were derived from the patient records. Follow-up was 30 days postoperatively. Outcomes were analyzed by the chi-square test and regression analysis. Clinical success was defined as a combination of technical success, improvement in the ankle-brachial index, increased walking distance and “no complications.” Results: The procedure was clinically successful in 74.4% of the patients, and in 25.6%, a complication occurred. The Rutherford class improved in 65.1% of the patients with 1.6 (SD 1.3) class points. The ankle-brachial index improved in 44.8% of the cases, with an average of 116.6%. The most contributing factors for complications such as death, unplanned amputation, surgical site infection, thrombosis and longer hospital admission were emergency operation and a higher ASA classification. Significantly more complications also occurred in patients with renal failure, congestive heart disease, a high Rutherford classification and previous groin incision. A higher Rutherford class was the only factor correlating with an increase in the ankle-brachial index. When single CFE (48.9% of cases) and hybrid procedures (51.1%) were compared, no significant difference in success or failure was found. Conclusion: Limb ischemia requiring emergency operation and preoperative comorbidity were identified as the most important factors predictive for complications following femoral artery endarterectomy. Combining femoral endarterectomy with an endovascular intervention does not seem to increase the risk of a postoperative complication. Full article

Background: Fournier’s gangrene (FG) is a rare necrotising soft tissue infection localised in the genital areas with possible dramatic outcomes. Recently, sodium glucose co-transporter-2 (SGLT2) inhibitors were identified as a risk factor. Methods: We present a case report of a 57-year-old female patient with type 2 diabetes mellitus (T2DM) in treatment with empagliflozin which led to the development of FG. Moreover, we performed a systematic review assessing the association between empagliflozin use and FG. Results: The female patient with 15-years treated diabetes presented a massive FG after 6 months from starting empagliflozin. Over the period of two months, she was successfully treated in a low-income setting. The systematic review included two studies with a total of 9915 participants. Although no participant had FG, there was an increased rate of urinary and genital infection in patients treated with empagliflozin compared to those treated with other antidiabetics or placebo. Conclusions: FG should be considered as a possible complication in patients using SGLT2. Patients should be educated to report early signs of genital infection and healthy behaviours as well as a balanced diet should be promoted to aid in the prevention of FG. Full article

Chyloperitoneum is defined as the presence of lymph within the peritoneal cavity, resulting from obstruction or injury of lymph ducts, mostly at the level of the gastrointestinal tract. This can occur in the context of congenital diseases, traumas, infections, neoplasms, hepatic disease, heart disease, and postoperative complications. The most common symptoms described are abdominal distention and mild pain in a course of weeks to months, with dyspnea, peritonitis, and in a few cases weight gain is observed due to the high intra-abdominal pressure. We present a case of a 56-year-old male with no significant personal history, who has a clinical picture of approximately three months of evolution, consisting in sensation of an abdominal mass predominantly in the left hemiabdomen, associated with progressive abdominal distension, changes in intestinal habit, lower limb edema, dyspepsia, occasional postprandial emesis, and unintentional weight loss of 20 kg. In non-traumatic conditions, the most frequent cause of chylous ascites is a malignancy disease followed by cirrhosis and mycobacterial infections. Taking into consideration that adenocarcinoma is the most frequently reported histologic subtype of jejunum neoplasm, and that not all cases of lymphoma debut with chylous ascites, it can be concluded that the proportion of patients that present with this condition is exceptionally low. Chyloperitoneum is an infrequent finding, having the higher detection rate in lymphatic alterations and malignancies of gastrointestinal location, in which some of the most commonly neoplasms associated with this complication are lymphoma, neuroendocrine tumors, sarcomas, and leukemia. Full article

Recently, the Hospital at Tabarre in Port-au-Prince Haiti was reopened by the Operational Center of Paris—Médecins Sans Frontières (MSF). This hospital is now purely a Trauma Center staffed by five national general surgeons and five orthopedic surgeons. MSF hopes that the new trauma focus of Tabarre Hospital and the presence of a full complement of experienced national surgeons can enable this site to become one of the training sites for exptriate surgeons on their first humanitarian mission with MSF. The general surgical case charts from the first 3 months after the reopening of the hospital were retrospectively reviewed. All procedures done by the general surgical department in the operating room theatre were registered and short and long-term results analyzed. The Hospital at Tabarre has a very high rate of penetrating traumas compared to other MSF hospitals, and seems ideally suited to train expatriate surgeons during their first missions in the field with MSF because of the experience of the National surgical staff. Additionally, it is felt that a longer Field General Surgery fellowship can and should be developed within MSF to ensure that the next generation of general surgeons can continue to provide the type of surgical care that is still needed in the field. Full article

Faecal incontinence (FI) is a debilitating symptom with a likely underreported incidence in the general population. Postpartum or postmenopausal women are at increased risk of this. General Practitioners (GPs) have a vital role in screening patient groups with FI. Knowledge of the underlying diseases associated with FI is important for all clinicians who have contact with this patient group. An online questionnaire (Survey Monkey^TM, San Mateo, CA, USA) was sent to GPs in Wales and England through a deanery, social media and GP educational groups. Questions: A total of 250 participants completed the questionnaire—195 GPs and 55 GPSTs. Two-thirds had no coloproctology experience, but 70% had worked in obstetrics and gynaecology. In total, 70% had no formal FI training and 75% felt insufficiently informed about FI. A total of 80% felt that GPs need specific training on FI. A third of respondents used the 6-week postnatal check to assess maternal bowel function and most did not appreciate faecal urgency as a symptom. Patients should be asked about FI symptoms by GPs, particularly those populations at increased risk. Our GP survey participants were enthusiastic for more education on the treatment options and where to signpost patients with FI. Full article

Congenital diaphragmatic hernia (CDH) is often diagnosed and treated in the perinatal period. Recurrence is a known complication that may very rarely occur years after the operation. We report here the case of a patient who had an operation for a CDH at birth that then recurred in adulthood. Given the risk of complications and the symptomatology of the patient, we decided to treat the patient surgically. We successfully performed a video-assisted thoracic surgery (VATS) procedure during which we reduced the hernia and closed the breach. Given the recurrent nature of the hernia, we decided to reinforce the repair with a mesh. Full article

Germ cell tumors (GCTs) are a common malignancy in males, with variations in differentiation making different therapeutic strategies necessary. Generally, GCTs show good curation rates due to their good response to radiotherapy or chemotherapy. However, certain subtypes are resistant to these therapies and require surgery. We present a case of a 25-year-old patient with a large retroperitoneal GCT with somatic malignant transformation, where resection of large abdominal blood vessels with complex reconstruction was necessary to completely remove the tumor. The tumor was completely resected, and the patient has since been recurrence-free in the follow-up period. GCTs with somatic transformation show high resistance rates to chemo- and radiotherapy, and the patient in the presented case study did indeed show only a limited response to carboplatin-based chemotherapy. Patients suffering from these conditions should be resected whenever possible, as curation can be achieved by complete tumor resection. Infiltration of neighboring structures is no contraindication to surgery. The case presented here shows that interdisciplinary surgical planning including vascular and general surgeons as well as radiologists is vital to ensure successful tumor resection. Full article

Osteochondritis dissecans (OCD) is a chronic disease of the articular cartilage characterized by focal lesions of subchondral bone and overlaying cartilage. Through the growing number of reports describing the high prevalence of OCD in some families, the subcategory termed familial OCD (FOCD) was established. With the development of genetic approaches such as genome-wide association studies and sequencing, aggrecan (ACAN) has been identified as one of the genes of interest associated with FOCD. Aggrecan is a crucial protein for the preservation and function of cartilage. However, due to FOCD being characterized relatively recently, there is a paucity of literature on the subject. The purpose of this review is to explore the relationship between ACAN mutations and familial OCD as well as to explore current treatment options and avenues for future research. In vitro and animal studies have shown the importance of ACAN in the preservation of cartilage. However, the only human ACAN mutation related to OCD ever identified is a V2303M mutation in the G3 domain. Multiple treatments have been superficially explored, and some options such as growth hormone (GH) and gonadotrophin-releasing hormone agonists (GnRHa) show potential. Thus, further research on FOCD in needed to identify other ACAN mutations and determine optimal treatment modalities for this patient population. Full article